Previous studies of home care as an alternative to institutional care have failed 1) to consistently target high-risk patients and 2) to incorporate the capacity to manage both inpatient and outpatient care. This study will examine the effectiveness of a team-managed hospital linked home care (TM/HLHC) model for two high-use patient populations: persons hospitalized with congestive heart failure (CHF) or for elective total joint replacement (TJR) of the hip or knee. Condition-specific home care protocols will be developed jointly by home care and physicians in order to maximize continuity of patient care. The model also emphasizes close communication and coordination between the home care team and the patient's attending physician. Four hundred twenty CHF and 196 TJR inpatients at a large university teaching hospital who meet study inclusion criteria and agree to participate will be randomized to either TM/HLHC or to customary care. Customary care services may include other home care services, short term rehabilitation hospital, nursing home and ambulatory care services. Consenting patients and their informal caregivers will be followed for one year and interviewed at baseline, one, six and twelve months post-discharge. All health care utilization will be tracked for all subjects over this time period. We hypothesize that TJR intervention subjects will experience significantly fewer short term rehabilitation hospital admissions at six months and will also experience the same or improved functional status, the same or improved lower extremity functioning, and increased satisfaction with care at one, six and 12 months. In contrast, CHF study patients will use significantly fewer acute hospital readmission days at 6 months and will experience the same or better functional status outcomes, the same or fewer cardiac symptoms, and will express greater satisfaction with care at one, six and 12 months. Caregivers burden will assessed at the same time intervals to determine whether it increases significantly in the intervention group.